An unannounced inspection took place after the death of a 54-year-old woman in March. The report published on World Mental Health Day urges 'all possible action' to mitigate the risk of people hanging themselves

Staff at a mental health hospital in Paignton have been ordered to take more steps to reduce the risk of people hanging themselves following a 'serious incident'.

The call comes after an inspection of Cypress Independent Hospital in Totnes Road by the Care Quality Commission which found it needs to improve safety and effectivness.

An unannounced inspection took place in July after a 54-year-old woman was found hanged in March. Nicola Dawn Boyd was found hanged in her room on March 19. She was born in Malta, and lived in Dartmouth. She was married, and a healthcare assistant by occupation.

A report has been published on Tuesday, which is World Mental Health Day.

The building next door to a doctor's surgery is a converted house, and not purpose-built as a hospital, and inspectors found 'multiple ligature points' from which people could attempt to hang themselves.

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The report mentions 'loose radiator covers' and 'roller blinds with long cords'. It says staff were unable to see all parts of the ward, and there were no mirrors to cover 'blind spots'.

When patients were assessed, the reports did not specifically include 'ligature risk'.

Cypress is expected to stop operating as a hospital in January 2018, with staff and patients moving to a new purpose-built location elsewhere.

It is managed by Community Care Trust (South West) trading as Step One Charity.

The report urges Cypress to take 'all possible action' to mitigate the risk of people hanging themselves before the service leaves the Totnes Road location.

Hospital Room

Staff reduced the risks by assessing patients and not admitting those who were known to be at risk of suicide. The CQC report points out that staff knew how to report incidents, the culture was open and transparent, and practices were improving.

Patients and staff were 'positive' about the service and patients told inspectors they felt safe there.

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At a previous inspection in January 2016 the CQC decided that Cypress 'required improvement' overall. It's core service required improvement to its safety and effectiveness while it was rated good for being 'responsive', 'caring' and 'well-led'.

A CQC spokesman said: "From a CQC perspective the provider reported the incident in line with requirements, and we undertook an inspection in response to the report to look at whether the provider was delivering safe and effective care to patients.

"Our understanding is that the investigation into the specific incident has been undertaken by the provider and they will publish a report once this has been concluded."

In response to the report Eilis Rainsford, CEO of Step One, said: “This was a very tragic incident. We welcome the commission’s findings and would stress that the safety and well-being of our patients is a priority. Cypress Hospital is not a secure facility but rather a short-stay 12 bed open unit, providing nurse-led support for people who are in or recovering from a mental health crisis. As the inspection report makes clear, measures are in place including not admitting patients who have a known risk of using a ligature. We can also confirm that we are on schedule to move the service to a new facility early in 2018.”

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